An Audit Report on the Department of State Health Services' Human Resources Management at State Mental Health Hospitals
July 2011
Report Number 11-044
Overall Conclusion
The Department of State Health Services' (Department) human resources practices are generally adequate to help ensure compliance with applicable laws, policies, and procedures regarding criminal history background checks, abuse and neglect searches, and training requirements for employees of state mental health hospitals (state hospitals). Specifically, the Department:
- Has a process to help ensure that it does not hire employees with (1) a criminal conviction that would bar them from employment at state hospitals or (2) a confirmed allegation of abuse or neglect. The Department conducted pre-employment criminal history background checks and searches of the Nurse Aide Registry, the Employee Misconduct Registry, and the Client Abuse and Neglect Reporting System (CANRS) as required. The Department also conducted an annual search of the Nurse Aide Registry and the Employee Misconduct Registry for all hospital employees as required.
- Has a training program to help ensure that state hospital staff and managers are trained in accordance with applicable laws, policies, and procedures. The Department also established procedures to monitor whether state hospital employees are complying with the Department's internal training goals.
- Established a process that helps ensure that state hospitals completely and accurately entered allegations of abuse and neglect into CANRS. In addition, the Department's process also helps to ensure that employees with confirmed allegations in Class I (serious physical or sexual abuse) were separated from employment as required by the Texas Administrative Code.
Auditors identified several weaknesses that the Department should address to improve its processes related to criminal history background checks, allegations of abuse and neglect, and the management of its information technology systems. Specifically, the Department should ensure that:
- State hospitals clearly identify positions that, if they become vacant, must be filled immediately on a temporary or interim basis pending a criminal history clearance and communicate that information to Health and Human Services-Human Resources.
- It completely and consistently documents volunteer information so that it can determine whether state hospitals comply with pre-assignment clearance requirements for volunteers.
- It provides documented guidance to state hospitals that clearly outlines the Texas Administrative Code requirement for entering confirmed allegations of abuse and neglect into CANRS within 30 calendar days.
- It implements the guidelines requiring state hospitals to report confirmed allegations of abuse and neglect to the appropriate state licensing authorities and that all state hospital employees are aware of the reporting requirements.
Furthermore, the Health and Human Services Commission should improve user access controls over the two information technology systems that the Department uses to track employee information to reduce the risk of unauthorized access and modification of data in those systems.
Auditors communicated less significant issues to Department management separately in writing.